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APPLICATION FOR CERTIFICATE OF INTERNATIONAL EDUCATIONAL CHARACTER
U.S. Department of State
Title of Program (or Series)
Producer
Director
Intended Audiences
GENERAL INFORMATION
Grade Level
Black and White
Color
Negative
Positive
Sound
Silent
Program Format
Slide/Transparency
Wall Chart/Map/Poster
Model
DESCRIPTION OF SLIDE OR TRANSPARENCYSlides/Transparencies
In. By In.
Number
Size
Records
Numbers
Size
CassettesNumber
DS-2038 (Formerly USIA IAP-17)02-2006
Motion Picture/Videotape/Videodisc
Recording (Includes CD/CDR/DVD Products) Other
Date of Production (mm-dd-yyyy)
Date of Release (mm-dd-yyyy)
Page 1 of 2
Summary of Content
Address of Applicant (Street, City, State, Zip Code)
Language(s) Used In
Name of Applicant (U.S. Holder of Basic Rights) (Last, First, MI)
DESCRIPTION OF MOTION PICTURE/VIDEOTAPE
Form
Format DVD
Cassette Diskette
CD-CDR Number of Units Length in Time
DESCRIPTION OF WALL CHART/MAP/POSTER
Wall Chart Map OtherPoster
Constituent Material
Dimensions By BoundSingleSheets
Sets ofSheets
DESCRIPTION OF MODELDimensions
Length Height Width MovingStatic
Predominant Colors
STATEMENT OF OWNERSHIP
Type or Print
Signature Date (mm-dd-yyyy)
Telephone E-Mail Address
* If materials are not fully owned by applicant, please explain or attach documentation.
ATTACH TO THIS APPLICATION A COMPLETE DESCRIPTION OF THE MATERIAL WITH THE EXACT WORDING OF TITLES, COPIES OF GUIDES, ETC., AND FORWARD THE MATERIAL, PREPAID, FOR REVIEW.
RETURN COMPLETED FORM
Fax Number: 202-203-7469
ECA-IIP/EXAttestation Officer of the United States
U.S. Department of State301 4th Street, SW
Washington, DC 20547
I, , hereby certify the applicant named
above is the owner of the basic rights to the material(s) described in this application.*
Title
Constituent Materials
Scale
Gauge
Length In Feet
Gauge
Cassette
Running Time
Hours Minutes
Videotape
DESCRIPTION OF RECORDING
Motion Picture
Page 2 of 2
Other
Description of Videodisc and other Motion Media Formats
Telephone Number: 202-203-7447
